Associated Home Health

Release Of Patient Identifiable Oasis Info.

The agency failed to maintain infection control practices to protect three (3) of three (3) patients receiving home Prothrombin and International Normalized Ratio values (PT/INR) by agency clinicians.

Accuracy Of Encoded Oasis Data

The agency failed to ensure each patient received home health services per an individualized plan of care.

Agency failed to provide services as ordered and failed to obtain physician's signature for Plan Of Care (POC) within seven (7) days for six (6) of ten (10) consumer records (CRs) reviewed.

The agency failed to ensure staff followed agency policy and procedure and manufacturers guidelines for cleaning/disinfecting equipment for three (3) of three (3) patients patients receiving home Prothrombin and International Normalized Ratio values (PT/INR) by agency clinicians and one (1) of…

The agency failed to obtain physician's signature for Plan Of Care (POC) within seven (7) days for four (4) of ten (10) consumer records (CRs) reviewed.

The agency failed to develop, implement, evaluate, and maintain an effective ongoing, HHA-wide, data driven QAPI (quality assessment program improvement) program specific to the licensed agency.

The governing body failed to maintain written evidence of appointed administrator responsible for all day to day operations of the home health agency was included an accurate organizational chart (0948); failed to document in writing the alternate administrator (0954); failed to ensure a qualified…

The agency failed to maintain documentary evidence of an effective, ongoing, HHA-wide, data-driven QAPI program specific to the licensed HHA.

The quality assessment and performance improvement program was performed at a corporate level and failed to individualize the data collected to monitor effectiveness and quality of care delivery, and failed to identify opportunities for improvement for 2017-2018 collection years. . Findings…

The agency failed to maintain documentation to demonstrate performance improvement projects conducted annually at the HHA (home health agency) for 2018. Findings included: Request made to EMP8 on 5/28/19 at approximately 10:15 a.m., for annual program evaluation with policies specific to the…

The governing body failed to ensure a HHA-wide quality assessment and performance improvement program was implemented at the licensed agency and identified priorities to evaluate include missed visits impact on plan of care delivery and documentation of coordination of care.

The administrator failed to assign a clinical manager qualified to provide oversight for all patient care services.

The agency had failed to prepare an overall plan/budget to include an annual operating budget and capital expenditure plan for the licensed agency.

The agency failed to treat patient/family as an active partner in the delivery of care by accommodation of requests or preferences for visit schedule for three (3) of nine (9) patients (CR1, CR6, CR7).

The agency failed to ensure the patient/caregiver were able to participate in the scheduling of home visits to accommodate the needs of the patient/caregiver in order to receive the benefits of the services approved by the plan of care for one (1) of nine (9) clinical records reviewed (CR1)…

Staff (EMP) the agency failed to ensure patients received all services outlined in the plan of care for one (1) of nine (9) clinical records (CR1).

The agency failed to follow-up with patient in writing for resolution to complaint for one (1) of two (2 ) complaints reviewed for 2019. Findings included: Review on 5/29/19 at approximately 1:30 p.m., of agency Policy No. 1-010 Complaint/Grievance Process, read "...1. The organization personnel…

The performance improvement activities failed to identify/focus on problem-prone/high volume of failed to document coordination of care and/or frequent missed visits that resulted in patients not receiving the services ordered on the plans of care for six (6) of nine (9) CR reviewed (CR1, CR4, CR5…

The agency failed to consider the incidence of lack of documented communication of coordination of care and/or frequent missed visits that resulted in patients not receiving the services ordered on the plans of care for six (6) of nine (9) CR reviewed (CR1, CR4, CR5, CR6, CR7, CR9).

When asked who was in charge, "corporate..." EMP8 was not aware of EMP12, "...no longer here I guess..." Review on 5/28/19 at approximately 11:05 a.m., Organizational chart identified administrator as EMP2, and alternate administrator as EMP4. Administrator (EMP2) was not available to surveyor…

A qualified clinical manager was not available during all operational hours on 6/13/19-6/14/19. Findings included: Review on 5/28/19 at approximately 11:05 a.m., Organizational chart identified administrator as EMP2, and alternate administrator as EMP4. Review on 6/13/19 at approximately 2:30 p.m.…

The administrator failed to assure all staff qualifications were met prior to assignment for two (2) of two (2) skilled nursing staff (EMP13 and EMP14) and one (1) of five (5) therapy staff (EMP3).

The agency failed to maintain in writing the governing body approval for the alternate administrator.

The agency failed to ensure effective interchange between disciplines to support the goals of the plans of treatment for six (6) of nine (9) clinical records reviewed (CR1, CR3, CR4, CR5, CR7, CR9).

The clinical manager failed to assure patient needs were continually assessed for six (6) of nine (9) clinical records reviewed (CR1, CR4, CR5, CR6, CR7, CR9).

The agency failed to ensure the physician ordering the plan of treatment was alerted to changes in a patient's condition that required an alteration in the plan of treatment for five (5) of nine (9) CR reviewed (CR1, CR4, CR5, CR7, CR9).